Modified Swenson procedure

Modified Swenson surgery for the surgical treatment of Hirschsprung's disease. Congenital megacolon is a common malformation of the digestive tract. It is caused by the lack of ganglion cells in the distal segment of the colon, resulting in intestinal fistula, normal peristalsis of the intestine segment disappearing, forming functional intestinal obstruction, obstructing proximal intestinal dilatation. Fat. The length of the intestines varies from a few centimeters, sometimes to the entire colon, and even to the small intestine. The latter has serious clinical symptoms and is complicated to treat. The most common type is the sigmoid colon below the sacral segment, and the proximal intestine near the sacral segment gradually expands until the dilated segment is called the transition segment. There is also a lack of ganglion cells in this segment of the intestine. In the dilated segment of the intestine muscle layer hypertrophy, chronic inflammation of the mucosa, and even ulceration, degeneration and spasm of the intermuscular plexus and submucosal ganglion cells. The length of the dilatation segment is also inconsistent with the age of the visit, and then gradually transitions to the normal intestine. Treatment of diseases: congenital megacolon Indication Children with congenital megacolon disease for more than 3 months (some authors advocate surgery in the neonatal period), after colostomy or strict bowel and bowel preparation, the general condition is better, no enteritis. Contraindications Severe malnutrition or combined with enterocolitis cannot tolerate surgery. The above-mentioned sick children should undergo colostomy first, and then the radical surgery should be performed after the general condition is improved. Congenital megacolon combined with other systemic severe malformations such as severe congenital heart disease, esophageal atresia, etc. should be performed first in the intestinal stoma, to be corrected for severely life-threatening deformities, and then megacolon radical surgery. Preoperative preparation In children with congenital megacolon, there is clinical colonic obstruction, abdominal distension, large amount of feces in the colon, absorption of toxins, malnutrition, impaired heart, liver and kidney function, and poor resistance. Therefore, system preparation should be performed before surgery. Surgery creates good conditions. 1. Preoperative barium enema, rectal manometry, rectal mucosal biopsy, cholinesterase determination, clear diagnosis and understanding of the extent of the lesion. 2. Preoperative blood and urine routine examination, liver and kidney function and electrocardiogram examination. 3. Prepare the bowel before surgery for colonic lavage with normal saline 3 weeks before surgery to remove the feces in the colon, relieve abdominal distension, restore intestinal tract, reduce symptoms of poisoning, improve nutritional status, and treat enteritis. The condition of the sick child is gradually improved, and the enema effectively relieves the functional colonic obstruction, so that the partially dilated bowel gradually returns to normal, which facilitates the scope of the resection in the operation. In colonic lavage should pay attention to: 1 must use isotonic saline, because low permeability liquid is easy to cause water poisoning, high permeability liquid is easy to cause salt poisoning. The most important thing is to accurately measure the amount of enema in and out, to prevent the instilled saline from staying in the intestine. The total amount of enema per time must not exceed 100ml/kg body weight. 2 enema should choose soft, but slightly thicker anal canal, easy to excrete feces from the anal canal. The enema should understand the extent and direction of the diseased bowel, and the tube should be gentle. Each time the enema is administered, the anal canal is passed through the sacral section to reach the dilatation section. Do not inject too much liquid each time, pour a certain amount of salt water, gently massage the abdomen, and squeeze the expansion section downwards, so that the gas, feces and liquid in the intestinal tract are discharged from the anal canal. After the daily enema, the purpose of cleaning the expansion section should be achieved. 3 In the winter enema, you should keep warm to prevent cold and respiratory infections. 4 For children with short sputum, you can pour "123 liquid" (ie 33% magnesium sulfate 30ml, glycerol 60ml, normal saline 90ml) before washing with normal saline. Infants can be half-infused, stimulate bowel movements, and then cleanse the intestines with saline. 4. If there is water and electrolyte disturbance, it should be corrected in time. Anemia can be transfused in small amounts. 5. Give low slag, easy to digest, high protein, high vitamin food during enema, give high nutrition in the intestine if necessary, actively improve malnutrition, and improve the body resistance of sick children. 6. Give intestinal sterilizing agent 3 days before surgery to reduce bacteria in the intestine and reduce the infection rate after surgery. 7. Preoperative blood. 8. Place the stomach tube before surgery, and place the catheter after disinfection in the operation area. Surgical procedure 1. Incision: Most of the left lower abdomen rectus abdominis incision or left lower abdomen oblique incision. 2. After opening the abdomen, the pelvic peritoneum is incision along the rectal bladder (or uterus) to properly protect the ureter. The tissues surrounding the rectum are separated by blunt and sharp. Close to the rectum during separation to avoid damage to the anterior tibial nerve. A full-thickness biopsy of the rectum and sigmoid colon is performed to determine the presence or absence of intermuscular ganglion cells. The sigmoid colon and the superior rectal artery are ligated and the latter can reduce the amount of bleeding during pelvic dissection and help the proximal bowel to be pulled to the perineum without tension. 3. Continue to separate down along the rectal wall, and use fingers to bluntly separate along the tailbone, straight to the lower end of the rectum below the tip of the tailbone, below the levator ani muscle, to facilitate perineal operation. 4. When the separation of the rectum is completed, the sigmoid colon and the descending mesenteric membrane are moved upward to the left curvature, so that the proximal colon can pull out the anus without tension. After the removal of the hypertrophic dilated bowel segment, the rectum and the proximal colonic stump were temporarily sutured with silk. 5. Use the long vascular clamp to pull the rectum out. After the rectum is turned out, the mucosa is disinfected with iodophor or neostigmine. Make a transverse incision in the anterior wall of the rectum near the anal canal, insert a long vascular clamp, clamp the suture of the proximal colon stump, and drag it out of the anus. The incision of the anterior wall of the rectum is incision and the front wall of the colon is pulled out, and the rectum and the colon are cut into two layers, and the two anesthesia are sutured 2-0, and the anastomosis is as close as possible to the anus, generally not more than 2 cm. When anastomosis, it should be sutured while cutting. After the anastomosis of the intestine is completed, the excess rectum and the colonic intestines that have been pulled out have been completely removed, and the rectum and anal canal are returned to the reduction position. 6. The longitudinal shape of the rectum on the back of the rectum is opened to make a "V" shape, carefully separating and removing the loose connective tissue around the rectum, so that the anastomosis of the rectum can be close to the muscle layer of the colon wall that is pulled out. The intestine wall is sandwiched with fat to avoid poor healing. 7. First, support lines are made on both sides of the top end of the "V"-shaped cutting edge, and one stitch is stitched at 3, 9, and 12 points as a mark. The lower end of the "V" shape, that is, the posterior wall of the rectum reaches the dentate line, and the rectum The marking line of the front wall, ie 12 o'clock, should be 2.5 cm from the dentate line to ensure that the anastomosis is heart-shaped. A circle of sarcoplasmic layer is sutured between the two intestinal walls to remove excess intestinal tube. 8. The two intestines were sutured in one full layer, and then the anastomosis was also incorporated into the pelvis, so that the anterior wall of the anastomosis was 5 cm from the anus and the posterior wall was about 2 cm. complication 1. The operation is relatively large, similar to Swenson's surgery. Postoperative attention should be paid to the observation of the condition to prevent shock. 2. Because the procedure is a heart-shaped anastomosis, the intestine is also included in the pelvic cavity after anastomosis. If the intestine is resected too much, there will be some tension between the retracted colon and the rectal heart-shaped anastomosis. If the tension is too large, anastomotic healing may occur. Good, so the mesentery should be fully freed during surgery to prevent excessive tension in the anastomosis.